Top

Published in:

01-04-2010 | Clinical Article

Increasing hematocrit above 28% during early resuscitative phase is not associated with decreased mortality following severe traumatic brain injury

Authors: Carole Flückiger, Markus Béchir, Mirko Brenni, Silke Ludwig, Jutta Sommerfeld, Silvia R. Cottini, Marius Keel, Reto Stocker, John F. Stover

Published in: Acta Neurochirurgica | Issue 4/2010

Abstract

Background

To prevent iatrogenic damage, transfusions of red blood cells should be avoided. For this, specific and reliable transfusion triggers must be defined. To date, the optimal hematocrit during the initial operating room (OR) phase is still unclear in patients with severe traumatic brain injury (TBI). We hypothesized that hematocrit values exceeding 28%, the local hematocrit target reached by the end of the initial OR phase, resulted in more complications, increased mortality, and impaired recovery compared to patients in whom hematocrit levels did not exceed 28%.

Methods

Impact of hematocrit (independent variable) reached by the end of the OR phase on mortality and morbidity determined by the extended Glasgow outcome scale (eGOS; dependent variables) was investigated retrospectively in 139 TBI patients. In addition, multiple logistic regression analysis was performed to identify additional important variables.

Findings

Following severe TBI, mortality and morbidity were neither aggravated by hematocrit above 28% reached by the end of the OR phase nor worsened by the required transfusions. Upon multiple logistic regression analysis, eGOS was significantly influenced by the highest intracranial pressure and the lowest cerebral perfusion pressure values during the initial OR phase.

Conclusions

Based on this retrospective observational analysis, increasing hematocrit above 28% during the initial OR phase following severe TBI was not associated with improved or worsened outcome. This questions the need for aggressive transfusion management. Prospective analysis is required to determine the lowest acceptable hematocrit value during the OR phase which neither increases mortality nor impairs recovery. For this, a larger caseload and early monitoring of cerebral metabolism and oxygenation are indispensable.

Carlson AP, Schermer CR, Lu SW (2006) Retrospective evaluation of anemia and transfusion in traumatic brain injury. J Trauma 61:567–571CrossRefPubMed

Cherry T, Steciuk M, Reddy VV, Marques MB (2008) Transfusion-related acute lung injury: past, present, and future. Am J Clin Pathol 129:287–297CrossRefPubMed

Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, MacIntyre NR, Shabot MM, Duh MS, Shapiro MJ (2004) The CRIT Study: anemia and blood transfusion in the critically ill—current clinical practice in the United States. Crit Care Med 32:39–52CrossRefPubMed

Duchesne JC, Hunt JP, Wahl G, Marr AB, Wang YZ, Weintraub SE, Wright MJ, McSwain NE Jr (2008) Review of current blood transfusions strategies in a mature level I trauma center: were we wrong for the last 60 years? J Trauma 65:272–276CrossRefPubMed

Ekelund A, Reinstrup P, Ryding E, Andersson AM, Molund T, Kristiansson KA, Romner B, Brandt L, Säveland H (2002) Effects of iso- and hypervolemic hemodilution on regional cerebral blood flow and oxygen delivery for patients with vasospasm after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 144:703–712CrossRef

Frietsch T, Lenz C, Kuschinsky W, Waschke KE (2004) Effects of chronic isovolaemic haemodilution on regional cerebral blood flow in conscious rats. Eur J Anaesthesiol 21:53–59PubMed

Ge YL, Lv R, Zhou W, Ma XX, Zhong TD, Duan ML (2007) Brain damage following severe acute normovolemic hemodilution in combination with controlled hypotension in rats. Acta Anaesthesiol Scand 51:1331–1337PubMedCrossRef

George ME, Skarda DE, Watts CR, Pham HD, Beilman GJ (2008) Aggressive red blood cell transfusion: no association with improved outcomes for victims of isolated traumatic brain injury. Neurocrit Care 8:337–343CrossRefPubMed

Gonzalez AM, Yazici I, Kusza K, Siemionow M (2007) Effects of fresh versus banked blood transfusions on microcirculatory hemodynamics and tissue oxygenation in the rat cremaster model. Surgery 141:630–639CrossRefPubMed

10.

Habib RH, Zacharias A, Schwann TA, Riordan CJ, Durham SJ, Shah A (2003) Adverse effects of low hematocrit during cardiopulmonary bypass in the adult: should current practice be changed? J Thorac Cardiovasc Surg 125:1438–1450CrossRefPubMed

11.

Han SH, Ham BM, Oh YS, Bahk JH, Ro YJ, Do SH, Park YS (2004) The effect of acute normovolemic haemodilution on cerebral oxygenation. Int J Clin Pract 58:903–906CrossRefPubMed

12.

Hare GM, Mazer CD, Hutchison JS, McLaren AT, Liu E, Rassouli A, Ai J, Shaye RE, Lockwood JA, Hawkins CE, Sikich N, To K, Baker AJ (2007) Severe hemodilutional anemia increases cerebral tissue injury following acute neurotrauma. J Appl Physiol 103:1021–1029CrossRefPubMed

13.

Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–417CrossRefPubMed

14.

Klein HG, Spahn DR, Carson JL (2007) Red blood cell transfusion in clinical practice. Lancet 370:415–426CrossRefPubMed

15.

Kroppenstedt SN, Thomale UW, Griebenow M, Sakowitz OW, Schaser KD, Mayr PS, Unterberg AW, Stover JF (2003) Effects of early and late intravenous norepinephrine infusion on cerebral perfusion, microcirculation, brain-tissue oxygenation, and edema formation in brain-injured rats. Crit Care Med 31:2211–2221CrossRefPubMed

16.

Leal-Noval SR, Muñoz-Gómez M, Arellano-Orden V, Marín-Caballos A, Amaya-Villar R, Marín A, Puppo-Moreno A, Ferrándiz-Millón C, Flores-Cordero JM, Murillo-Cabezas F (2008) Impact of age of transfused blood on cerebral oxygenation in male patients with severe traumatic brain injury. Crit Care Med 36:1290–1296CrossRefPubMed

17.

Leal-Noval SR, Múñoz-Gómez M, Murillo-Cabezas F (2008) Optimal hemoglobin concentration in patients with subarachnoid hemorrhage, acute ischemic stroke and traumatic brain injury. Curr Opin Crit Care 14:156–162CrossRefPubMed

18.

Leal-Noval SR, Rincón-Ferrari MD, Marin-Niebla A, Cayuela A, Arellano-Orden V, Marín-Caballos A, Amaya-Villar R, Ferrándiz-Millón C, Murillo-Cabeza F (2006) Transfusion of erythrocyte concentrates produces a variable increment on cerebral oxygenation in patients with severe traumatic brain injury: a preliminary study. Intensive Care Med 32:1733–1740CrossRefPubMed

19.

Madjdpour C, Spahn DR, Weiskopf RB (2006) Anemia and perioperative red blood cell transfusion: a matter of tolerance. Crit Care Med 34(5 Suppl):S102–S108CrossRefPubMed

20.

Marik PE, Corwin HL (2008) Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med 36:2667–2674CrossRefPubMed

21.

McHugh GS, Engel DC, Butcher I, Steyerberg EW, Lu J, Mushkudiani N, Hernández AV, Marmarou A, Maas AI, Murray GD (2007) Prognostic value of secondary insults in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:287–293CrossRefPubMed

22.

McIntyre LA, Fergusson DA, Hutchison JS, Pagliarello G, Marshall JC, Yetisir E, Hare GM, Hébert PC (2006) Effect of a liberal versus restrictive transfusion strategy on mortality in patients with moderate to severe head injury. Neurocrit Care 5:4–9CrossRefPubMed

23.

McIntyre LA, Hebert PC (2006) Can we safely restrict transfusion in trauma patients? Curr Opin Crit Care 12:575–583CrossRefPubMed

24.

McIntyre L, Hebert PC, Wells G, Fergusson D, Marshall J, Yetisir E, Blajchman MJ, Canadian Critical Care Trials Group (2004) Is a restrictive transfusion strategy safe for resuscitated and critically ill trauma patients? J Trauma 57:563–568CrossRefPubMed

25.

Meier R, Béchir M, Ludwig S, Sommerfeld J, Keel M, Steiger P, Stocker R, Stover JF (2008) Differential temporal profile of lowered blood glucose levels (3.5 to 6.5 mmol/l versus 5 to 8 mmol/l) in patients with severe traumatic brain injury. Crit Care 12:R98CrossRefPubMed

26.

Meixensberger J, Kunze E, Barcsay E, Vaeth A, Roosen K (2001) Clinical cerebral microdialysis: brain metabolism and brain tissue oxygenation after acute brain injury. Neurol Res 23:801–806CrossRefPubMed

27.

Meixensberger J, Renner C, Simanowski R, Schmidtke A, Dings J, Roosen K (2004) Influence of cerebral oxygenation following severe head injury on neuropsychological testing. Neurol Res 26:414–417CrossRefPubMed

28.

Rosenthal G, Hemphill JC, Sorani M, Martin C, Morabito D, Meeker M, Wang V, Manley GT (2008) The role of lung function in brain tissue oxygenation following traumatic brain injury. J Neurosurg 108:59–65CrossRefPubMed

29.

Sarrafzadeh AS, Kiening KL, Callsen TA, Unterberg AW (2003) Metabolic changes during impending and manifest cerebral hypoxia in traumatic brain injury. Br J Neurosurg 17:340–346CrossRefPubMed

30.

Smith MJ, Stiefel MF, Magge S, Frangos S, Bloom S, Gracias V, Le Roux PD (2005) Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med 33:1104–1108CrossRefPubMed

31.

Thomale UW, Bender M, Casalis P, Rupprecht S, Griebenow M, Neumann K, Woiciechowsky C, Unterberg AW, Stover JF (2007) Tacrolimus depresses local immune cell infiltration but fails to reduce cortical contusion volume in brain-injured rats. Immunobiology 212:567–576CrossRefPubMed

32.

Thomale UW, Kroppenstedt SN, Beyer TF, Schaser KD, Unterberg AW, Stover JF (2002) Temporal profile of cortical perfusion and microcirculation after controlled cortical impact injury in rats. J Neurotrauma 19:403–413CrossRefPubMed

33.

Tinmouth A, Fergusson D, Yee IC, Hébert PC, ABLE Investigators; Canadian Critical Care Trials Group (2006) Clinical consequences of red cell storage in the critically ill. Transfusion 46:2014–2027CrossRefPubMed

34.

Tomiyama Y, Brian JE Jr, Todd MM (2000) Plasma viscosity and cerebral blood flow. Am J Physiol Heart Circ Physiol 279:H1949–H1954PubMed

35.

Tomiyama Y, Jansen K, Brian JE Jr, Todd MM (1999) Hemodilution, cerebral O2 delivery, and cerebral blood flow: a study using hyperbaric oxygenation. Am J Physiol 276:H1190–H1196PubMed

36.

Treggiari MM, Schutz N, Yanez ND, Romand JA (2007) Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Neurocrit Care 6:104–112CrossRefPubMed

37.

Tsai AG, Cabrales P, Intaglietta M (2004) Microvascular perfusion upon exchange transfusion with stored red blood cells in normovolemic anemic conditions. Transfusion 44:1626–1634CrossRefPubMed

38.

Tschuor C, Asmis LM, Lenzlinger PM, Tanner M, Härter L, Keel M, Stocker R, Stover JF (2008) In vitro norepinephrine significantly activates isolated platelets from healthy volunteers and critically ill patients following severe traumatic brain injury. Crit Care 12:R80CrossRefPubMed

39.

Van Beek JG, Mushkudiani NA, Steyerberg EW, Butcher I, McHugh GS, Lu J, Marmarou A, Murray GD, Maas AI (2007) Prognostic value of admission laboratory parameters in traumatic brain injury: results from the IMPACT study. J Neurotrauma 24:315–328CrossRefPubMed

40.

van Bommel J, Trouwborst A, Schwarte L, Siegemund M, Ince C, Henny ChP (2002) Intestinal and cerebral oxygenation during severe isovolemic hemodilution and subsequent hyperoxic ventilation in a pig model. Anesthesiology 97:660–670CrossRefPubMed

41.

Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, Meier-Hellmann A, Nollet G, Peres-Bota D, ABC (Anemia and Blood Transfusion in Critical Care) Investigators (2002) Anemia and blood transfusion in critically ill patients. JAMA 288:1499–1507CrossRefPubMed

42.

Weinberg JA, McGwin G Jr, Griffin RL, Huynh VQ, Cherry SA 3rd, Marques MB, Reiff DA, Kerby JD, Rue LW 3rd (2008) Age of transfused blood: an independent predictor of mortality despite universal leukoreduction. J Trauma 65:279–282CrossRefPubMed

43.

Weiskopf RB, Feiner J, Hopf H, Lieberman J, Finlay HE, Quah C, Kramer JH, Bostrom A, Toy P (2006) Fresh blood and aged stored blood are equally efficacious in immediately reversing anemia-induced brain oxygenation deficits in humans. Anesthesiology 104:911–920CrossRefPubMed

44.

Weiskopf RB, Kramer JH, Viele M, Neumann M, Feiner JR, Watson JJ, Hopf HW, Toy P (2000) Acute severe isovolemic anemia impairs cognitive function and memory in humans. Anesthesiology 92:1646–1652CrossRefPubMed

45.

Weiskopf RB, Toy P, Hopf HW, Feiner J, Finlay HE, Takahashi M, Bostrom A, Songster C, Aminoff MJ (2005) Acute isovolemic anemia impairs central processing as determined by P300 latency. Clin Neurophysiol 116:1028–1032CrossRefPubMed

46.

Zauner A, Daugherty WP, Bullock MR, Warner DS (2002) Brain oxygenation and energy metabolism: part I-biological function and pathophysiology. Neurosurgery 51:289–301CrossRefPubMed

Title: Increasing hematocrit above 28% during early resuscitative phase is not associated with decreased mortality following severe traumatic brain injury
Authors: Carole Flückiger
Markus Béchir
Mirko Brenni
Silke Ludwig
Jutta Sommerfeld
Silvia R. Cottini
Marius Keel
Reto Stocker
John F. Stover
Publication date: 01-04-2010
Publisher: Springer Vienna
Published in: Acta Neurochirurgica / Issue 4/2010
Print ISSN: 0001-6268
Electronic ISSN: 0942-0940
DOI: https://doi.org/10.1007/s00701-009-0579-8

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Increasing hematocrit above 28% during early resuscitative phase is not associated with decreased mortality following severe traumatic brain injury

Abstract

Background

Methods

Findings

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Methods

Findings

Conclusions

Please log in to get access to this content

Other articles of this Issue 4/2010

Relationships between brain tumor and optic tract or calcarine fissure are involved in visual field deficits after surgery for brain tumor

Intra-operative MRI-assisted spinal localization

Brain abscess following endoscopic ligation of esophageal varicose veins

Fulminant fatal meningitis following partial resection of an endodermal cyst

Early acute hemispheric stroke after carotid endarterectomy. Pathogenesis and management

Standard and limitation of intraoperative monitoring of the visual evoked potential